Management of Greater Trochanter Fractures of the Femur
For isolated greater trochanter fractures, conservative non-surgical management is the recommended first-line treatment, as most heal well without surgical intervention and have good functional outcomes. 1
Classification and Assessment
Greater trochanter fractures can occur as:
- Isolated fractures
- Part of more complex hip fractures (intertrochanteric, subtrochanteric)
- Iatrogenic fractures during hip replacement surgery
- Associated with osteolytic lesions
Initial Evaluation
- Radiographic assessment: Ventrodorsal projections are most effective for diagnosis, with frog-leg views providing enhanced visualization 2
- MRI confirmation may be needed for suspected non-displaced fractures
- Assess for concurrent injuries, particularly coxofemoral luxations which commonly occur with these fractures
Treatment Algorithm
1. Isolated Greater Trochanter Fractures
Conservative Management (First-line approach)
- Indicated for most isolated greater trochanter fractures with displacement <2 cm 3, 1
- Protocol:
- Limited weight-bearing with assistive devices
- Pain management with multimodal analgesia (including preoperative nerve blocks if surgery is needed) 4
- Progressive mobilization
- Rehabilitation program with early physical training and muscle strengthening
Surgical Management
- Consider for:
- Surgical options:
2. Greater Trochanter Fractures as Part of Complex Hip Fractures
Intertrochanteric Fractures
- For stable intertrochanteric fractures: sliding hip screw 4
- For unstable intertrochanteric fractures: antegrade cephalomedullary nail 4
Subtrochanteric/Reverse Obliquity Fractures
- Cephalomedullary device is strongly recommended 4
3. Iatrogenic Greater Trochanter Fractures During Hip Arthroplasty
- If identified during surgery: wire fixation 6
- If identified postoperatively: conservative management unless significantly displaced (>2 cm) or associated with prosthesis dislocation 3, 6
Postoperative Care
- Multimodal analgesia incorporating preoperative nerve blocks 4
- Tranexamic acid administration to reduce blood loss and transfusion requirements 4
- Abduction orthosis for surgically treated fractures 5
- Protected weight-bearing for at least 3 months after surgical fixation 5
- Early mobilization with appropriate assistive devices 4
- Interdisciplinary care programs to decrease complications and improve outcomes 4
Rehabilitation Protocol
- Early postfracture introduction of physical training
- Muscle strengthening focused on hip abductors
- Long-term continuation of balance training
- Fall prevention strategies 4
Monitoring and Follow-up
- Regular radiographic assessment to monitor healing (average healing time: 5 months) 5
- Clinical evaluation of pain, mobility, and function
- Assessment for complications:
- Nonunion (rare in conservatively managed cases) 3
- Hardware failure
- Persistent pain or limp
Pitfalls and Caveats
Displacement assessment is critical - fractures with >2 cm displacement have poorer outcomes with conservative management and may benefit from surgical intervention 3, 1
Patient compliance with weight-bearing restrictions and orthosis use significantly impacts outcomes - the one documented treatment failure in surgical cases was associated with non-compliance with abduction orthosis use 5
Isolated greater trochanter fractures are often stable and rarely lead to hip dislocation, unlike what might be expected with significant abductor mechanism disruption 3
Direction of displacement is typically medially and superiorly toward the femoral head, rather than directly superior as seen in ununited trochanteric osteotomies 3
Conservative management requires patience - improvement in pain and limp may take several months 3